Perceptions of, and Practices for Coping with, Heat Exposure among Male Arab Pilgrims to the Hajj, 1436

Recommended water immersion duration for the field treatment of exertional heat stroke when rectal temperature is unavailable

INTRODUCTION

The recommended treatment for exertional heat stroke is immediate, whole-body immersion in < 10 °C water until rectal temperature (Tre) reaches ≤ 38.6 °C. However, real-time Tre assessment is not always feasible or available in field settings or emergency situations. We defined and validated immersion durations for water temperatures of 2-26 °C for treating exertional heat stroke.

METHODS

We compiled data for 54 men and 18 women from 7 previous laboratory studies and derived immersion durations for reaching 38.6 °C Tre. The resulting immersion durations were validated against the durations of cold-water immersion used to treat 162 (98 men; 64 women) exertional heat stroke cases at the Falmouth Road Race between 1984 and 2011.

RESULTS

Age, height, weight, body surface area, body fat, fat mass, lean body mass, and peak oxygen uptake were weakly associated with the cooling time to a safe Tre of 38.6 °C during immersions to 2-26 °C water (R2 range: 0.00-0.16). Using a specificity criterion of 0.9, receiver operating characteristics curve analysis showed that exertional heat stroke patients must be immersed for 11-12 min when water temperature is ≤ 9 °C, and for 18-19 min when water temperature is 10-26 °C (Cohen's Kappa: 0.32-0.75, p < 0.001; diagnostic odds ratio: 8.63-103.27).

CONCLUSION

The reported immersion durations are effective for > 90% of exertional heat stroke patients with pre-immersion Tre of 39.5-42.8 °C. When available, real-time Tre monitoring is the standard of care to accurately diagnose and treat exertional heat stroke, avoiding adverse health outcomes associated with under- or over-cooling, and for implementing cool-first transport second exertional heat stroke policies.

Risk factors for heat-related illnesses during the Hajj mass gathering: an expert review

Human exposure to a hot environment may result in various heat-related illnesses (HRIs), which range in severity from mild and moderate forms to life-threatening heatstroke. The Hajj is one of the largest annual mass gatherings globally and has historically been associated with HRIs. Hajj attracts over two million Muslim pilgrims from more than 180 countries to the holy city of Makkah, Kingdom of Saudi Arabia. Several modifiable and non-modifiable factors render Hajj pilgrims at increased risk of developing HRIs during Hajj. These include characteristics of the Hajj, its location, population, and rituals, as well as pilgrims' knowledge of HRIs and their attitude and behavior. Makkah is characterized by a hot desert climate and fluctuating levels of relative humidity. Pilgrims are very diverse ethnically and geographically, with different adaptations to heat. Significant proportions of the Hajj population are elderly, obese, and with low levels of fitness. In addition, many have underlying health conditions and are on multiple medications that can interfere with thermoregulation. Other factors are inherent in the Hajj and its activities, including crowding, physically demanding outdoor rituals, and a high frequency of infection and febrile illness. Pilgrims generally lack awareness of HRIs, and their uptake of preventive measures is variable. In addition, many engage in hazardous behaviors that increase their risk of HRIs. These include performing rituals during the peak sunshine hours with no sun protection and with suboptimal sleep, nutrition, and hydration, while neglecting treatment for their chronic conditions. HRIs preventive plans for Hajj should incorporate measures to address the aforementioned factors to reduce the burden of these illnesses in future Hajj seasons. Lessons from the Hajj can be used to inform policy making and HRIs preventive measures in the general population worldwide.

Mitigation strategies for heat-related illness during mass gatherings: Hajj experience

Introduction

To mitigate morbidity, mortality, and impacts of heat-related illnesses (HRIs) on health, it was vital to implement a comprehensive framework for HRI prevention and control. A recognized tool from the field of trauma prevention known as the Haddon matrix was applied. The matrix states that any event is affected by three factors: host, agent, and environment. In addition, another recognized tool known as the combined model was used in this study. The combined model is a three-dimensional model that includes the idea for the three axes of Haddon's matrix with the methodology of the community risk reduction (CRR) model.

Aim of the study

To identify the environmental and individual risk factors of HRIs based on the Haddon matrix and the recommended prevention strategies by the CRR tool by using the combined model.

Methodology

An extensive literature review was conducted to assess all the risk factors associated with HRI, as well as preventive measures. Then the Haddon matrix was used to structure, separating human factors from technical and environmental details and timing. After that, the combined model was used to set all responses and mitigation measures for each element obtained from the Haddon matrix tool.

Conclusion

Projected increases in heat stress over the globe require the formulation and implementation of evidence-based HRI mitigation and preventive measures. In this study, we implemented the combined model that was utilized as a systematic strategy for the more theoretical framework of Haddon's matrix. Using the Haddon matrix to determine the HRI risk factors and the combined model to mitigate its impact was practical and helpful in planning, preparedness, and mitigating the HRIs during Hajj, provided a broad approach equivalent to the Swiss cheese model, and would facilitate an informed decision.

Analysis of Outdoor Thermal Discomfort Over the Kingdom of Saudi Arabia

In this study, the variability and trends of the outdoor thermal discomfort index (DI) in the Kingdom of Saudi Arabia (KSA) were analyzed over the 39-year period of 1980-2018. The hourly DI was estimated based on air temperature and relative humidity data obtained from the next-generation global reanalysis from the European Center for Medium-Range Weather Forecasts and in-house high-resolution regional reanalysis generated using an assimilative Weather Research Forecast (WRF) model. The DI exceeds 28°C, that is, the threshold for human discomfort, in all summer months (June to September) over most parts of the KSA due to a combination of consistently high temperatures and relative humidity. The DI is greater than 28°C for 8-16 h over the western parts of KSA and north of the central Red Sea. A DI of >28°C persistes for 7-9 h over the Red Sea and western KSA for 90% of summer days. The spatial extent and number of days with DI > 30°C, that is, the threshold for severe human discomfort, are significantly lower than those with DI > 28°C. Long-term trends in the number of days with DI > 28°C indicate a reduced rate of increase or even a decrease over some parts of the southwestern KSA in recent decades (1999-2018). Areas with DI > 30°C, in particular the northwestern regions of the Arabian Gulf and its adjoining regions, also showed improved comfort levels during recent decades. Significant increases in population and urbanization have been reported throughout the KSA during the study period. Analysis of five-years clinical data suggests a positive correlation between higher temperatures and humidity with heat-related deaths during the Hajj pilgrimage. The information provided herein is expected to aid national authorities and policymakers in developing necessary strategies to mitigate the exposure of humans to high levels of thermal discomfort in the KSA.

Knowledge, Attitude and Practice of Pilgrims Regarding Heat-Related Illnesses during the 2017 Hajj Mass Gathering

The Hajj mass gathering attended by over two million Muslim pilgrims from around the world is a risk for heat-related illnesses (HRIs). We investigated the knowledge, attitude and practice (KAP) of pilgrims attending the 2017 Hajj regarding HRIs and their prevention. Adult pilgrims (1801) from six countries in Africa, Asia and the Middle East were interviewed using a structured questionnaire. Pilgrims had a mean age of 47.2 years (SD = 12.6) and a male:female ratio of 2.2:1. Over 83% declared having at least a secondary education. Pilgrims generally had good knowledge and above average attitude and practice according to our scoring criteria. Most pilgrims were aware of HRIs and preventive measures. However, poor hydration and reluctance to use certain preventive measures or to change Hajj activities’ schedule based on environmental temperature were noted. Age, nationality and level of education were significantly associated with a good knowledge of HRIs. Only nationality was significantly associated with good attitude, and good practice was significantly associated with gender, age and nationality. There were significant positive correlations between the KAP scores. These results can serve as baseline data to design effective general or targeted interventions to improve pilgrims’ knowledge and behavior and to reduce their risk of HRIs during Hajj.